Hip fractures: mortality, economic burden, and organisational factors for improved patient outcomes
Authors: Enwu Liu
Journal: The Lancet Healthy Longevity (2023)

Hip fractures are associated with high mortality and a substantial economic burden. Although many studies have investigated patient characteristics or surgical procedures related to mortality and economic burden, very few have examined the hospital-level factors associated with hip fracture mortality and costs.1Guzon-Illescas O Perez Fernandez E Crespí Villarias N et al.Mortality after osteoporotic hip fracture: incidence, trends, and associated factors.J Orthop Surg Res. 2019; 14: 203Crossref PubMed Scopus (161) Google Scholar, 2Liu E Killington M Cameron ID Li R Kurrle S Crotty M Life expectancy of older people living in aged care facilities after a hip fracture.Sci Rep. 2021; 1120266Google Scholar, 3Tan CMP Park DH Chen YD Jagadish MU Su S Premchand AXR Mortality rates for hip fracture patients managed surgically and conservatively in a dedicated unit in Singapore.Arch Orthop Trauma Surg. 2022; 142: 99-104Crossref PubMed Scopus (3) Google Scholar Petra Baji and colleagues’ study in The Lancet Healthy Longevity4Baji P Patel R Judge A et al.Organisational factors associated with hospital costs and patient mortality in the 365 days following hip fracture in England and Wales (REDUCE): a record-linkage cohort study.Lancet Healthy Longev. 2023; (published online July 10.)https://doi.org/10.1016/S2666-7568(23)00086-7Google Scholar addresses an important research gap by focusing on multiple organisational factors. By examining the variation in hip fracture care delivery in 172 National Health Service hospitals in England and Wales, the findings have implications for researchers, clinicians, and health service funders and managers. The authors investigated 89 organisational factors that were relevant to costs and length of patient stay in the hospital, and 105 factors that were relevant to mortality outcomes within 365 days of an index hip fracture. The findings showed that 11 organisational factors were independently associated with mortality at 365 days, including six factors associated with a reduced risk of death and five factors associated with an increased risk of death. Not surprisingly, well organised multidisciplinary services who openly reported re-operation rates and included patient experience in governance meetings had better mortality outcomes. Additionally, 25 organisational factors were found to be independently associated with hospital inpatient costs (12 associated with lower costs and 13 associated with higher costs) in the 365 days following hip fracture. The findings underscore the importance of appropriate resource allocation for patients with hip fracture in England and Wales. For example, employing physiotherapists appears to be a good investment. Costs were reduced in hospitals that invested in physiotherapy provision over the weekend, and also by hospitals with sufficient resources to enable more than 71% of patients to be mobilised within one day of their surgery. Nutritional assessment of older patients also yielded savings. But more was not always better: an optimal amount of geriatrician input was found to be ideal, beyond which, even with additional clinician involvement, inefficiencies emerged. Older people with hip fractures often have pre-existing chronic diseases and frailty, and should be managed within a multidisciplinary clinical system. Providing evidence of the connection between organisational factors and reductions in length of stay can help clinicians to argue for quality multidisciplinary care systems provided over 7 days after hip fracture surgery. International organisations such as the Fragility Fracture Network emphasise three key pillars of quality care for patients with hip fracture: multidisciplinary care during acute care, rapid secondary prevention (ie, addressing falls and osteoporosis), and access to post-acute care or rehabilitation.5Dreinhöfer KE Mitchell PJ Bégué T et al.A global call to action to improve the care of people with fragility fractures.Injury. 2018; 49: 1393-1397Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Information on access to rehabilitation and community recovery services is comparatively scant in Baji and colleagues’ report, partly because such data were difficult to collect, but also because rehabilitation is often regarded as an optional extra. The quality of the recovery (including walking independence) achieved during the hospital stay in this study is unknown, and might have contributed to the 1-year outcomes. A hip fracture is often a life-changing event, and as many as 50% of older people who walked before a fracture never recover their prefracture walking ability or regain the same level of functional independence.6Dyer SM Crotty M Fairhall N et al.A critical review of the long-term disability outcomes following hip fracture.BMC Geriatr. 2016; 16: 158Crossref PubMed Scopus (424) Google Scholar In May, 2023, the World Health Assembly passed a resolution entitled “Strengthening rehabilitation in health systems”, which affirms rehabilitation as an essential health strategy that should be delivered as part of universal health coverage.7WHOStrengthening rehabilitation in health systems.https://apps.who.int/gb/ebwha/pdf_files/EB152/B152%2810%29-en.pdfDate: 2023Date accessed: May 30, 2023Google Scholar Countries and health systems are encouraged to improve their health information systems to gather data and ensure effective monitoring of coverage. Poor access to rehabilitation exposes patients to high risks of long-term loss of functioning, marginalisation, and institutionalisation, and variations in access should be measured and minimised. Although Baji and colleagues’ study makes a valuable contribution to the existing literature, key questions remain to be addressed. This study focuses on all-cause mortality, but what is the cause-specific mortality of hip fractures? What are the effects of competing risks from other diseases? Additionally, what are the costs associated with other diseases for patients with hip fracture, considering the high prevalence of comorbidities among older individuals?8Lloyd R Baker G MacDonald J Thompson NW Co-morbidities in patients with a hip fracture.Ulster Med J. 2019; 88: 162-166PubMed Google Scholar Exploring these additional specific questions could provide a more comprehensive understanding of the topic. Fractures are referred to as a tracer condition, which provide rich information on the quality of processes in health systems for older people.9Kassim Javaid M Chana J Cooper C Hip fracture as the tracer condition.Best Pract Res Clin Rheumatol. 2013; 27: 711-715Crossref PubMed Scopus (0) Google Scholar Given its association with older age and the rate of ageing of the global population, hip fractures are likely to become even more frequent events to bring patients to health-care systems worldwide, and monitoring treatments and outcomes of this group of patients will not only extend the scope of knowledge about the quality of care provided to patients, but also facilitate a deeper understanding of how best to care for older people. I declare no competing interests. Organisational factors associated with hospital costs and patient mortality in the 365 days following hip fracture in England and Wales (REDUCE): a record-linkage cohort studyMultiple, potentially modifiable hospital-level organisational factors associated with important clinical outcomes and inpatient costs were identified that should inform initiatives to improve the effectiveness and efficiency of hip fracture services. Full-Text PDF Open Access